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THE RISK MANAGEMENT MAGAZINE OF THE CANADIAN MEDICAL PROTECTIVE ASSOCIATION
Perspective
VOLUME 6 | NO. 2
JUNE 2014
WHAT’S INSIDE
A STATE OF MIND
Risk in psychiatric practice
ELECTRONIC
RECORDS
10 tips to avoid pitfalls
SPOTLIGHT
Medical marijuana
TRAUMATIC
COMPARTMENT
SYNDROME
LONG-TERM CARE
Quality decisions
F E AT U R E
The physician voice
When advocacy leads to change
Physicians are advocates for their patients and for
healthcare improvements, but this dimension of
medical care can be challenging.
iStock, johavel
A challenging diagnosis
contents
JUNE/SUMMER 2014
03 WHAT’S NEW
FIND OUT what the CMPA is doing to enhance its services and
help you practise medicine safely.
04 SPOTLIGHT:
Medical marijuana: Guidance for Canadian doctors
PHYSICIANS SHOULD BE FAMILIAR with the Marihuana for
Medical Purposes Regulations (MMPR), which came into effect
on April 1, 2014.
05 A state of mind:
Examining risk in psychiatric practice
PSYCHIATRISTS WORK CLOSELY with patients and their
families to manage complicated, often difficult-to-treat mental,
emotional, and behavioural disorders.
08 10 tips for using electronic records
AS THE USE OF eRecords increases, pitfalls and liability issues are
emerging. Follow 10 tips which can help physicians mitigate risk.
CMPA PERSPECTIVE, JUNE 2014
VOL. 6 NO. 2, P1402E
© The Canadian Medical Protective Association
2014 — All reproduction rights reserved.
Publications mail agreement number 40069188.
CMPA Perspective magazine is published
quarterly and is available in digital
format at cmpa-acpm.ca. A special edition
is also published annually.
Ce document est aussi offert en français.
Address all correspondence to:
The Canadian Medical Protective Association
P.O. Box 8225, Station T, Ottawa, ON K1G 3H7
Telephone: 1-800-267-6522, 613-725-2000
(Monday to Friday, 8:30 a.m. to 4:30 p.m. ET)
Facsimile: 1-877-763-1300, 613-725-1300
Email: [email protected]
Website: cmpa-acpm.ca
The information contained in this publication
is for general educational purposes only and is
not intended to provide specific professional
medical or legal advice, or to constitute a
“standard of care” for Canadian healthcare
professionals. Your use of CMPA learning
resources is subject to the foregoing as well as
the complete disclaimer, which can be found
at cmpa-acpm.ca; enter the site and go to
“Terms of use“ at the bottom of the page.
10 FEATURE:
The physician voice: When advocacy leads to change
PHYSICIANS ARE ADVOCATES for their patients and for
healthcare improvements, but this dimension of medical care
can be challenging.
14 A challenging diagnosis:
Traumatic compartment syndrome
MEASURES FOR REDUCING medico-legal risk in the diagnosis
of traumatic compartment syndrome of the lower limb, based on
5 years of CMPA members’ experience.
17 Long-term care: Quality decisions
AS PHYSICIANS MAY face unique issues when caring for
residents of long-term care facilities, being aware of risks will
prove beneficial to the provision of safe care.
2 CMPA PERSPECTIVE
June 2014
WHAT’S
NEW
Electronic Records Handbook:
Wondering how to implement and
use electronic medical/health records?
The CMPA’s updated Electronic Records
Handbook answers your questions with
the latest advice on security, sharing data,
selecting an appropriate system, and much
more. Read it in the Advice & Publications
section of the CMPA website.
We are phasing out cheques: The CMPA
is phasing out cheques as a method for
paying membership fees. If you pay your
fees by cheque, you’ll need to change to
one of our pre-authorized debit (PAD)
payment methods. And coming in 2015,
membership fee invoices will be available
only online. Visit the CMPA website to learn
more about these changes.
Good practices in cultural safety:
Recognizing and respecting cultural
differences is an important element of
medical practice. The CMPA Good Practices
Guide has a new section on cultural
safety to help you deliver culturally
competent and safe medical care.
Available at cmpa-acpm.ca/gpg.
Updated Governing Law and
Jurisdiction Agreement: The CMPA and
Healthcare Insurance Reciprocal of Canada
(HIROC) have updated the “Governing
Law and Jurisdiction Agreement” forms,
which are designed for use by physicians
in private practice and healthcare
organizations if providing treatment to
non-residents of Canada. The forms are
available at cmpa-acpm.ca.
From the CEO
What is the role of big data in medical care? It’s a timely question,
and one that we explored with you in a recent CMPA eBulletin.
We asked, “How will big data affect your medical practice in
the future?” The majority of respondents (47%) admitted not
knowing enough about the implications of big data; others (25%)
indicated big data will facilitate better clinical decision-making;
or help personalize medicine in the future (10%). Interestingly, a
small number of members (18%) felt big data would not impact
their medical practice.
While there are varying perspectives on the value and risks of big
data, there is general consensus that the collection and use of
large data sets will impact the healthcare system in many ways.
Experts will advance that big data holds the promise of better,
more personal, and effective care. Others will argue that big data,
if not handled properly, will infringe on patients’ privacy rights.
The opportunity is upon the medical profession to become
aware of and knowledgeable about big data, and for doctors
to play a role in the way data analytics evolve. The aim should
be to derive the maximum benefits from data, while ensuring
physicians’ professional obligations are fulfilled and patients’
health information is safeguarded. I maintain doctors want to be
familiar with the concept and utility of big data, and attentive to
the related opportunities and risks.
It is timely for physicians to come together to explore the
implications of big data. Doctors are central to finding the
right balance between leveraging the advantages of big data
(enhanced care, service delivery, resource management) with
legitimate privacy issues.
Given the timeliness of the issue, the CMPA information session
which follows our annual meeting will focus on big data. I invite
you to join us in Ottawa on August 20th, as we assemble an
expert panel to discuss the benefits, risks, and implications of
big data on medical care. If you’re unable to join us, the session
will be available as a delayed webcast at cmpa-acpm.ca in
late August.
Exclusive online articles:
Visit cmpa-acpm.ca for articles you won’t
see anywhere else, including: “Providing
quality end-of-life care” and “Know the
rules, avoid the risks: Treating family
and friends.”
Hartley Stern, MD, FRCSC, FACS
June 2014
CMPA PERSPECTIVE 3
spotlight
MEDICAL MARIJUANA
Guidance for Canadian doctors
The new Marihuana for Medical Purposes
Regulations (MMPR) came into effect
on April 1, 2014, replacing the former
regulations, the Medical Marihuana
Medical Access Regulations. Doctors must
be familiar with the new regulations, and
should know and abide by their College’s
policies.
Regulations
The aim of the MMPR is to treat marijuana as
much as possible like other narcotics used for
medical purposes. Under the new regulations, a
patient must consult with a prescribed healthcare
practitioner, a physician or a qualified nurse
practitioner, and obtain a signed “medical
document.” The patient then submits the medical
document directly to a licensed commercial
producer to obtain the medical marijuana.1
Alternatively, arrangements can be made for the
producer to transfer the drug to the healthcare
practitioner who signed the medical document,
and the patient can obtain it from the healthcare
practitioner.
College policies
The medical community is adjusting to the new
regulations, while continuing to express concern
about the lack of scientific evidence on the risks
and benefits of medical marijuana.
Some common themes among current College
policies and guidelines:
• Doctors are under no obligation to provide
patients with a medical document to access
the drug.
• Should a physician consider providing the
medical document, the consent discussion
should be noted in the medical record. The
discussion should include information about
the known risks and benefits of the drug, as
well as the lack of scientific evidence.
• An assessment of the patient’s clinical
condition, potential risks, and appropriate
follow up or reassessment is mandated by
several Colleges.
4 CMPA PERSPECTIVE
June 2014
Some of the notable variances in the Colleges’
policies:
• In British Columbia and Prince Edward Island,
physicians must avoid using telemedicine to
complete the medical document.
• In Alberta, doctors who choose to complete
a medical document must register this
information with the College.
• In Saskatchewan, physicians must obtain a
signed, written treatment agreement from
patients that spells out the patients’ obligations,
including using the marijuana as prescribed.
Physicians must keep a separate record
containing the names, quantities, medical
conditions, and licensed producer (if known)
for all relevant patients, and provide this
record to the College on a regular basis and
upon request.
• In New Brunswick, physicians who complete
medical documents are required to warn
patients about obtaining marijuana from
another source, redirecting their drug to
another individual, as well as maintaining their
supply in a secure place.
• In Newfoundland and Labrador, physicians
who are considering completing a medical
document are expected to follow 8 conditions
including assessing the patient for risk of
addiction using a standardized addiction risk
tool and establishing an individualized written
protocol for periodic reassessment of the
patient receiving marijuana.
• In Québec, physicians are prohibited from
providing a medical document to access
medical marijuana unless the patient is
enrolled in a recognized research study and
only for specified conditions.
Physicians will want to be familiar with their
College policies and can contact the CMPA for
assistance. n
1. At the time of writing, the Federal Court injunction remains in place allowing
those who have a personal production licence (from the previous regulations) to
grow medical marijuana to continue until the court issues a final decision. Health
Canada is appealing this ruling.
A STATE OF MIND
Examining risk in psychiatric
practice
Psychiatrists work closely with
patients and their families to manage
complicated, often difficult-to-treat
mental, emotional, and behavioural
disorders. These specialists also
coordinate care with a variety of other
health professionals and agencies.
T
HE CMPA REVIEWED 881 legal and
medical regulatory authority (College)
cases involving psychiatrists that closed
between 2008 and 2013. The majority of these
were College complaints. Notably, in more than
half of the cases, the legal action was dismissed
or the College, following investigation, supported
the care provided by the psychiatrist. The
most common criticisms related to issues of
professionalism include inappropriate manner,
boundary crossings, and confidentiality breaches.
Deficient risk assessment and medication
management were the most common clinical
issues. Communication and documentation issues
were recurring themes across the cases.
Risk assessment
Allegations of inadequate assessment often arose
when a patient committed suicide while under
the care of a psychiatrist. Though rare, allegations
also occurred in cases where a psychiatric patient
committed a criminal act or an act of violence
against someone.
Peer experts supported the care provided by the
psychiatrist in the majority of cases involving
patient suicide, self-harm, or violence.
The main areas of concern identified in
unfavourable decisions were inadequate
assessments, including not soliciting collateral
or secondary information when appropriate;
inadequate monitoring; or not reassessing a
patient before extending privileges (e.g. allowing
day passes) or before discharging from hospital.
Meanwhile, incomplete documentation of the
assessment or treatment plan often made it
puckillustrations, Fotolia
difficult to evaluate the rationale behind care
decisions.
Poor coordination of care was often a factor when
suicide occurred in hospital (e.g. other healthcare
providers not advising the psychiatrist of a change
in the patient’s condition). Inadequate monitoring
protocols or unsafe environments (e.g. unsecure
windows, too easy access to medications) were
contributing factors in some cases.
In these types of cases, both the hospital
and the psychiatrist(s) are often named
and generally share liability.
It is widely recognized that suicide may be
unpredictable and that appropriate care may not
prevent an unfortunate outcome. A thorough
assessment and relevant documentation in the
patient record can help defend a complaint or legal
action involving patient suicide.
June 2014
CMPA PERSPECTIVE 5
CASE 1: INADEQUATE DOCUMENTATION
CALLS INTO QUESTION THE RISK
ASSESSMENT
CASE 2: DOCUMENTATION OF
ASSESSMENT SUPPORTS CARE
DECISIONS
A psychiatrist prescribes lorazepam for her
patient’s new complaints of anxiety. She has been
seeing him regularly for the past 2 years for the
treatment of schizoaffective disorder with frequent
auditory hallucinations, as well as depression and
compulsive behaviours. Despite the new symptoms,
the psychiatrist notes that he appears more cheerful
than usual. One week later, the patient dies from
an intentional overdose of antidepressants that he
is also taking. The patient’s family files a College
complaint alleging the psychiatrist mismanaged the
patient’s condition. While experts are not critical
of the psychiatrist’s overall treatment plan, the
College finds the documentation in the medical
record lacking in detail. A peer assessor is critical
that the psychiatrist did not detail the nature of the
patient’s auditory hallucinations, noting that such
information can uncover a heightened suicidal risk,
as in the case of a patient who is having command
hallucinations to end their life. The psychiatrist is
required to attend the College for a verbal caution.
An on-call psychiatrist assesses a new patient
who has presented to the emergency department
with complaints of depression. He concludes that
this patient shows symptoms of chronic social
dysfunction and depression, but judges he is not
actively suicidal. The psychiatrist changes the
patient’s antidepressant. He arranges for a follow-up
appointment in 5 weeks, when he plans to evaluate
the need for psychometric testing. Three weeks
later, the patient commits suicide. The patient’s
family files a College complaint alleging the
psychiatrist did not thoroughly assess the patient.
Expert review of the medical record finds careful
documentation of the patient encounter including
details on the patient’s family history of depression
and the assessment of suicidal risk. The College
concludes that the psychiatrist’s judgment was
reasonable, while acknowledging that the outcome
was tragic for all involved.
Many cases that
involved medication
issues were also
criticized by experts
for inadequate
documentation,
particularly
in relation to
the rationale
for selecting
or adjusting
medications or the
consent discussion.
Fotolia, alexsokolov
GettyImages, Steve Debenport
Medication management
Professional conduct
Prescribing medication is a significant part of
psychiatric practice. However, a documented
medication issue made up a small portion of
CMPA cases. While these cases represented
a diverse range of issues, inadequate consent
discussions with respect to drug side effects
and, to a lesser extent, monitoring issues were
recurring themes.
Issues related to professional conduct emerged in
a large number of cases. These usually involved
breaches of confidentiality or criticism of the
psychiatrist’s manner. There were also instances
of boundary transgression.
Many cases that involved medication issues
were also criticized by experts for inadequate
documentation, particularly in relation to the
rationale for selecting or adjusting medications or
the consent discussion.
6 CMPA PERSPECTIVE
June 2014
Boundary issues ranged from inappropriate
self-disclosure and conducting therapy sessions
in informal settings, to engaging in sexual
relationships with patients. The Canadian
Psychiatric Association has stated that “the unique
nature of the psychiatrist-patient relationship
has the potential for progression into boundary
violations,”1 and cautions psychiatrists to
remain vigilant to avoid this risk. Psychiatrists
are encouraged to consult peer supervisors
or resources available from their professional
associations. Most Colleges provide information
on their websites about boundary issues.
Patients receiving care for psychiatric conditions,
and their families, may be especially sensitive to
the physician’s demeanour or communication
style. This can lead to a complaint. Experts in these
cases have reinforced the need for psychiatrists to
be sensitive and respectful of patients and their
families and to ensure the reasons for clinical
decisions are understood.
Beyond boundary and communication issues,
breaches of confidentiality were also common
complaints. These mainly involved disclosing
personal information to third parties without
the patient’s consent. For example, speaking to a
member of the patient’s family about the condition
without the patient’s consent or providing too
much information in response to a third-party
request. This commonly included providing
personal information to an insurer or employer
not considered relevant to the understanding of
the patient’s condition. The latter scenario was
more common.
Given the importance of trust in
the therapeutic relationship, and the
sensitive nature of the information
shared between patient and
psychiatrist, understanding privacy
legislation and duty of confidentiality
is imperative to the profession.
The landmark 1999 Supreme Court
of Canada case, Smith v. Jones,
articulated the factors for when it
may be permissible to disclose patient
information in the context of the duty
to warn of a threat to public safety.2
Risk management considerations
Psychiatrists should consider the following
suggestions, based on expert opinion in the
cases reviewed:
• Be aware of potential boundary issues inherent
in the psychiatrist-patient relationship.
• Consider the need for collateral information
from the patient’s family, when appropriate.
• Ensure that documentation reflects the
assessment of the patient’s condition, supports
the diagnosis and the rationale for the
treatment plan, and includes the risk of suicide
when necessary.
• Before prescribing medication, conduct
a consent discussion with the patient or
substitute decision-maker that includes
discussion of benefits, risks, side effects, and
alternative choices.
• Carefully document consent discussions in the
patient’s record.
• When prescribing a medication, order
baseline and ongoing laboratory investigations,
as required.
• When reinstating a patient’s privileges,
adjusting medications or discharging a patient,
document decisions in the patient’s record.
• Provide only the information required on
third-party forms.
• Ensure communication with patients and
families remains sensitive and respectful at
all times.
• Work collaboratively with all providers to
reduce safety issues within the facility.
Members with specific concerns related to any of
the issues discussed in this article should contact
the CMPA for advice. n
ADDITIONAL READING AT
cmpa-acpm.ca
“Foreseeability: What is expected of a physician?”
“The complexity of psychotropic medication”
Good Practices Guide — sections on “Respecting
boundaries”
“Sharing information”
1. Canadian Psychiatric Association, “Sexual relationships with patients,” Position
statement, 2011. Accessed March 2014 from:
http ://publications.cpa-apc.org/media.php?mid=192
2. Chaimowitz G, Glancy G, Blackburn J., “The duty to warn and protect—impact on
practice,” Canadian Journal of Psychiatry (2000) Vol. 45 No. 10, p.899–904
June 2014
CMPA PERSPECTIVE 7
10 TIPS FOR USING
Electronic records
1
Phase-in the rollout
When a new electronic record
system is being implemented, it
carries a higher risk for errors as
the system is unfamiliar to users.
A phased rollout with appropriate
training is considered best.
Everyone using the record system,
including physicians, should be
trained on the software and use it
in a consistent way.
2
Clarify accountabilities
Fotolia, peshkova
Electronic patient records support
high quality and safe care by
making the personal health
information of patients readily
available to the healthcare
providers who need it.
As the use of eRecords increases,
pitfalls and liability issues are
emerging. The following 10 tips
can help physicians mitigate risk.
From the onset, physicians will
want to clarify ownership of
records, custody, access, storage,
copying, disposal, and also
transferring of records should
a physician decide to leave a
group practice. A data sharing
agreement, which is a requirement
in many jurisdictions, will prove
beneficial in establishing clear
accountabilities. The written
agreement generally helps to
articulate the role of each user and
who has access to the information
in the system and to what
extent. It also helps clarify who is
responsible for maintaining the
information in the system.
3
Have a backup plan
Computers sometimes fail,
records can be lost, and liability
may follow. Systems should be
backed-up regularly and antivirus
protection should be used.
Vendors should confirm in writing
that a backup function is in place
and working.
Quality assurance reviews should
be conducted periodically to
confirm the system is functioning
properly and contingency plans
should be in place in case of a
prolonged system disruption.
8 CMPA PERSPECTIVE
June 2014
4
Establish good routines
early
Physicians should enter
information carefully and as
soon as possible following the
patient encounter. Patient names,
identifiers, and the date and time
should be double-checked.
Be careful to select carefully
from menus. For example, drug
names may look or sound the
same. Double-check the starting,
escalation, maintenance, and
tapering dosages.
5
Respect privacy and
confidentiality
Only healthcare professionals
included in the delivery of care
should have access to a patient’s
health information and only on a
need-to-know basis. To monitor
usage, electronic record systems
are generally required to have
an audit capability to record
the details of access and use.
While audit requirements vary
between jurisdictions, they often
include the identity, date, time
and duration of access; password
protection to an identifiable user;
changes or additions to notes; and
which documents were viewed
and for how long. The software’s
audit capability should never be
disabled for any reason.
To protect patient information,
providers should consider the
following:
• Ensure the system is equipped
with robust security features
including encryption,
passwords, and access controls
to protect against unauthorized
access.
• Never use someone else’s
password when accessing the
patient’s record.
• Actively log off when tasks are
completed. Leaving the system
open allows access by another
individual under the first
provider’s user name. Systems
should have an automatic
log-off if left inactive for a set
period of time.
• Ensure all trainees have their
own login identifications that
are distinct and different from
supervisors and staff.
• Put a policy in place for
the “lockbox, masking, or
blocking” feature for protected
or sequestered records, and
for dealing with lockboxed
information when the patient
requests a transfer of records.
6
Think encryption
Lost or stolen laptops, office
computer systems, CDs, DVDs,
memory sticks, portable USB
drives, and other mobile devices
containing unencrypted copies of
patient information represent a
significant medico-legal risk and
expense. Password protection,
although important, does not
equal encryption. Some privacy
commissioners and medical
regulatory authorities (Colleges)
have stated that physicians and
other custodians must encrypt
patient information stored
on mobile devices. The CMPA
recommends that all devices and
systems containing patient health
information be encrypted.
7
Use automatic features
with care
For efficiency, computers can be
programmed to automatically
populate information fields (e.g.
past illnesses and medication lists)
from one visit to the patient’s next
visit. While this can be beneficial
at times, auto-population can also
skew the record of the visit, and
introduce some risks.
Such automatic features may
potentially compromise the
credibility of a physician if the
detail of the entry inaccurately
indicates what was done at the
time. This documentation could
be challenged as not representing
what actually happened at a
particular visit.
Physicians should:
• Record each individual patient
encounter to reflect what
actually occurred.
• Consider using short free-text
notes to describe the clinical
encounter and the rationale
for decision-making instead of
lengthy click-box templates.
8
Use decision aids correctly
Many electronic record systems
have decision-making tools such
as clinical practice guidelines,
clinical reminders, and automatic
pop-ups of recommendations for
drug choice. These can include
alerts and warnings related to
contraindications and potential
drug interactions. Some even have
tools to help with the formulation
of differential diagnoses.
All tools should be carefully
chosen to be congruent with
reasonable and current standards
of practice. They should not
be used as a replacement for
a physician’s own judgment.
Physicians should assess each
suggestion offered by a tool,
taking into consideration the
individual circumstances of
the case. On the other hand,
inappropriately overriding or
turning off system prompts and
warnings may also negatively
impact patient safety and the
defence of subsequent medicolegal problems. While the use of
these tools is not yet part of the
standard of care, if they are not
to be used, then this decision
should be stated in the facility’s
administrative policies.
Physicians should also be aware
of alert fatigue. It is important
to always consider whether the
alert information is relevant for
a particular patient. The audit
function in a system will indicate
which alerts were viewed and for
how long.
Recommendations, warnings, and alerts that are located
away from the centre of the computer screen can
be missed. It is often important to enter a clear note
indicating the thought process that led to a treatment
choice that differs from the one suggested. It may
be prudent to inform the patient of the reasons for
the decision.
9
Track tests and referrals
The electronic system should be used to track, action, and
file test results. Poor clinical outcomes resulting from missed
appointments, failures to follow up, and lost lab tests and
diagnostic imaging reports are common causes of patient
complaints and legal actions. A robust tracking capability
for tests and referrals, including for pending results, is an
important consideration in selecting an electronic system.
10
Make changes properly
Corrections can be made in an electronic record,
but must be done properly to avoid the appearance
of deliberate falsification. The overwriting of
electronic information, even if incorrect, might be
misconstrued as improper alteration of the patient
record. The audit function will indicate who made
any entries or changes and when.
Never change the existing entries after learning
of a complaint or action. Correcting an electronic
record should be made in a manner that is as
consistent as possible with College requirements
for paper records. If information is incorrect or
incomplete then this needs to be rectified.
If information in a lab report is incorrect, the
physician and the lab should work together
to correct it. If appropriate, they should also
consider how best to improve the system to limit
such problems in the future. If others need to be
informed of the amendments, the actions taken
and responses should be documented. n
ADDITIONAL READING AT
cmpa-acpm.ca
Electronic Records Handbook, 2014
June 2014
CMPA PERSPECTIVE 9
feature
THE PHYSICIAN VOICE
When advocacy leads to change
iStock, johavel
KEY LEARNINGS:
• Physicians will want to advocate for quality
of care issues and be engaged in healthcare
system improvements.
• Physicians can be effective advocates for their
patients by selecting appropriate strategies and
communication channels, including respecting
medical regulatory authorities (Colleges), hospital,
or institutional guidance on this matter.
• Physicians will want to remain open to the
perspectives of others, even when these views are
contrary to their own.
• Respectful discussions with patients, colleagues,
other healthcare professionals, and administrators
will generally strengthen collaboration and yield
good results.
10 CMPA PERSPECTIVE
June 2014
• When advocating, physicians should advance
an informed perspective based on evidence
where possible.
• Physicians will want to assess their level of
objectivity with the matter, and consider
their suitability to engage and achieve the
intended outcome.
• Physicians must recognize that misdirected or
inappropriate advocacy can be disruptive to the
provision of care and to safety, as well as hamper
the functioning of a care team.
ADVOCACY is typically
defined as support or argument for
a cause or a person.
P
HYSICIANS ARE ADVOCATES for their
patients and for healthcare improvements,
but this dimension of medical care can be
challenging if physician advocacy is not well
understood. Numerous definitions and various
interpretations of the term can make it difficult for
doctors to determine what advocacy approaches
will be effective and considered appropriate.
A deep tradition
Advocacy has a long and deep tradition in
medicine. Dr. Rudolf Virchow, one of the most
prominent physicians of the 19th century and
known as the father of modern pathology, said
physicians were “natural attorneys of the poor.”1
Recognizing the credibility associated with the
medical profession, physicians have traditionally
been called upon to speak up on behalf of patients
or others in need, and to influence policy or
program changes.
Advocacy is imbedded in many aspects of the
medical profession, and as a result, medical
associations or organizations have identified
programs, policies, and statements that define
the role of physicians in advocacy. The Canadian
Medical Association states doctors “must be able
to freely advocate when necessary on behalf of
their patients and should do so in a way that
respects the views of others and is likely to
bring about meaningful change that will benefit
their patients and the healthcare system.”2
Health advocacy is also one of the core roles
for physicians as outlined by the Royal College
of Physicians and Surgeons of Canada and the
College of Family Physicians of Canada. As well,
many Colleges have indicated it is generally
appropriate for doctors to advocate responsibly,
and advocacy should not interrupt the safe
provision of care.
lead to accusations of overstepping bounds,
irresponsibility, or inappropriate behaviours
and actions.
Healthcare advocacy by physicians can occur at
many levels and can take different forms. For
example, doctors often advocate for individual
patients by requesting timely diagnostic tests or
referral to a specialist. Physicians may advocate
at the regional level or for groups of patients, by
supporting an expanded community health centre
or by seeking funding for a health provider to join
a hospital. At the system level, physicians may
advocate for a provincial medical association’s
strategy or activities to improve healthcare overall.
Advocacy can also be global, for instance, when
physicians support health-related environmental
protection.
Advocacy strategies can vary from one-on-one
discussions with those in authority, to letter
writing and social media campaigns. Physicians
will want to consider the appropriateness of
the campaign, and their role within it. Prior
to engaging in any public advocacy activity,
physicians should consider whether it is necessary
or appropriate to discuss the planned activity
with parties who may be affected (e.g. patient/
family, other members of the care team, clinic,
hospital, health authority, etc.). While it is
generally a courtesy for physicians working in
hospitals to notify the hospital administration
in advance, some hospitals may require that
express permission be obtained before a physician
embarks on activities that could be interpreted
Advocacy at many levels
While advocacy is intrinsic to a physician’s role,
the approaches to fulfilling this responsibility
may sometimes be a cause of difficulty.
Ambiguity about what is the appropriate level
of advocacy and the general approaches can
lead to misunderstandings or conflicts between
physicians, or between physicians and other
individuals or groups. This uncertainty can also
alphaspirit, Fotolia
June 2014
CMPA PERSPECTIVE 11
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as being on behalf of the hospital. Hospitals,
institutions, and health authorities may have
policies or guidelines on the role of physicians
in advocacy activities, including media or social
media campaigns. When speaking publicly,
physicians should be clear when their comments
are made in a personal capacity or on behalf of a
third party. The CMPA recognizes there may sometimes be
ambiguity regarding what constitutes appropriate
advocacy. The Association believes physicians
should remain engaged in healthcare decisionmaking and advocate in a professional manner for
the interests of patients and the healthcare system.
For example, many physicians strongly support
health promotion initiatives such as influenza
vaccines, while others avoid doing so. Some
doctors may back patients in their quest for new
healthcare programs or encourage new disease
treatment options or promote innovation at the
point of care. All of these activities are appropriate
as long as physicians act professionally, provide an
12 CMPA PERSPECTIVE
June 2014
informed perspective, and offer constructive input
and recommendations to the appropriate groups
or individuals.
Learning about advocacy
Medical students and doctors may be attracted
to medicine because of the impact that medical
care, including advocacy, can have on individuals
and society. Trainees and new physicians are
increasingly exposed to a wide spectrum of
patients including refugees, the homeless, and
other disadvantaged patient groups.
Doctors are well-positioned to identify areas
for health system change and to recommend
improvements. While many physicians are very
skilled advocates, these abilities are not necessarily
natural for all doctors. Most often, advocacy is a
learned skill.
While physician advocacy is increasingly
discussed in undergraduate and postgraduate
medical curricula, medical students and
physicians may wish to seek out other sources of
information and training. The Canadian Medical
Association offers an advocacy skills training
program that includes tips for meeting members
of parliament, an overview of how government
works, media training, and communicating key
messages.3
Colleges have also made efforts to guide or
clarify how physicians can advocate effectively.
For example, the College of Physicians and
Surgeons of Alberta signaled its intention to
help physicians understand how, when, and
under what circumstances they can advocate
effectively. In Ontario, the College has approved a
policy on Physician Behaviour in the Professional
Environment that recognizes advocacy as an
important component of the doctor-patient
relationship.4 In Québec the advocacy role is
embedded in the Code of Ethics of Physicians. The
College has indicated doctors have a responsibility,
individually and collectively, to advocate for their
patients, while ensuring the delivery of quality
healthcare is not impaired by these efforts.5
Advocating in institutions
Physicians working in private practice may
feel more at ease to advocate for patients or for
changes. Meanwhile, physicians working in
healthcare institutions may face more complexity.
For example, doctors working in facilities may
have to channel their recommendations for
change through committees, or chiefs of divisions/
departments. Hospitals or health regions may have
guidelines on how to advocate for improvements.
There may be organizational bylaws or policies
that outline how to advocate on behalf of patients
or health system issues. In some instances, this has
led to disagreements between individual doctors
and hospitals or health authorities.
As healthcare providers and leaders, physicians
can help improve and sustain the health system.
This may include being involved in structural
changes, priority setting, resource allocation
decisions, quality improvement projects, or
initiatives to improve patient safety, among other
matters. All who advocate within the system must
demonstrate recognition of competing demands.
Physician advocacy should be accompanied by
evidence of that awareness.6
When advocating within their institutions,
the CMPA recommends doctors:
• Approach the issue with transparency,
professionalism, and integrity.
• Work within approved channels of
communication.
• Discuss concerns, suggestions, and
recommendations calmly.
• Provide an informed perspective, and attempt
to include the perspectives of patients and other
healthcare professionals.
• Persuade rather than threaten or menace others.
• Remain open to alternative suggestions or
solutions, and try to build on areas of consensus.
Final thoughts
The challenges facing physicians in today’s practice
environment are growing at the same time that
patients face a complex and shifting healthcare
system. As a result, patients will continue to look
to their doctor as a trusted source for healthcare
information and support. Consequently, it is likely
advocacy will only increase in importance. While
the definition of appropriate advocacy in healthcare
is evolving, physicians can show leadership by
remaining engaged and seeking to advance their
viewpoints in a professional and appropriate manner.
Members with questions or concerns about advocacy
should contact the CMPA to discuss these with a
medical officer. n
1. Arya, Neil, “Advocacy as Medical Responsibility,” Canadian Medical Association Journal
(2013) Vol. 185, no. 15 p.1368
2. Canadian Medical Association, “The Evolving Professional Relationship between
Canadian Physicians and Our Health Care System: Where Do We Stand?” 2012, p.14.
Retrieved November 27 2013 from:
http://policybase.cma.ca / dbtw-wpd/Policypdf / PD12-04.pdf
3. Canadian Medical Association, Advocacy skills training. Retrieved February 20 2014
from: http://ww w. cma.ca/ index.php?ci_id=89600&la_id=1
4. College of Physicians and Surgeons of Ontario, “Physician Behaviour in the
Professional Environment,” Policy Statement #4-07. Retrieved November 11 2013
from: http://www. cpso.on.ca / policies / policies/default.aspx?ID=1602
5. Collège des médecins du Québec, “Code of ethics of physicians.” Retrieved on
May 15 2014 from ht tp://aldo.cmq.org / en/Partie%201 / AspecDeonto/
DevoirObligations/CodeDeonto.aspx
6. Wasylenko, Eric, “Jugglers, tightrope walkers, and ringmasters: Priority setting,
allocation, and reducing moral burden,” Healthcare Management Forum
(Summer 2013) Vol. 26, no. 2 p.79
June 2014
CMPA PERSPECTIVE 13
A CHALLENGING DIAGNOSIS
Traumatic compartment
syndrome
Traumatic compartment syndrome
of the lower limb is a serious clinical
problem. It happens most commonly
after major trauma or fracture. However,
it may also occur after minor trauma or
for other reasons. Early diagnosis is often
challenging. Due to its rapidly evolving
and aggressive nature, delays in diagnosis
frequently lead to poor clinical outcomes
for patients.
was also seen as a complication of
surgeries such as tibial osteotomy,
revascularization procedures, and cosmetic
calf augmentation. A few cases were
exercise-induced or spontaneous in
nature, rendering a tough diagnosis even
more difficult. The vast majority of patients
in these cases were left with permanent
injury including major scarring, foot drop,
and in a few cases, amputation.
From 2003–2013 the CMPA closed 66
cases involving compartment syndrome.
Most cases were related to traumatic
leg injury or its repair, but the condition
Since compartment syndrome is a
recognized complication of trauma
and certain types of surgery, the poor
outcomes in some of the cases were not
always the result of the care provided.
However, the condition continues to be
an area of increased risk, with about half
of the cases resulting in an unfavourable
medico-legal outcome for physicians.
Unfavourable medico-legal outcomes
for physicians were often associated
with delays in diagnosis that resulted in
permanent injury. Some resulted from a
performance issue during surgery (e.g.
vascular injury during tubal ligation or
improperly performed calf augmentation).
fotolia, Verletzung im Schienbein
In the cases where the care was criticized,
communication breakdown between
healthcare providers was the most
common issue. Inadequate monitoring
or documentation, and failing to include
compartment syndrome in the differential
diagnosis were also associated with poor
outcomes. Failing to include the risk of
compartment syndrome in the consent
discussion was an issue in several cases.
14 CMPA PERSPECTIVE
June 2014
CASE EXAMPLES
CASE 1: ATYPICAL PRESENTATION
LEADS TO A DELAY IN DIAGNOSIS
A
31-YEAR-OLD IS BROUGHT to the
emergency department (ED) of a community
hospital by ambulance after collapsing during
exercise. He complains of pain in the front of both
lower legs with numbness and weakness. His legs are
tense, with pain on passive inversion of the ankle.
The physician suspects exertional compartment
syndrome and consults an orthopaedic surgeon
who recommends conservative management and
overnight observation. There is no improvement
overnight despite liberal doses of narcotics. Another
physician reassesses the patient and determines
that he has severe shin splints. The patient, still in
considerable pain, is discharged.
stretch, weakness, and palpable tenseness of the
compartment. Given that most compartment
syndromes occur as the result of a fracture, the
assessment of the origin of the pain is often
problematic. In addition, physical examination of the
limb may be limited by large dressings or casts.
To date, no reliable clinical guidelines for the
diagnosis of compartment syndrome have been
established. Pressure measurements of the
compartment can be helpful in establishing the
diagnosis. Once identified, fasciotomy is necessary
to relieve compartment pressures and preserve
compromised tissues. The patient’s outcome is
influenced by the length of time from the onset of
symptoms to the time of fasciotomy.
Traumatic compartment
syndrome continues to
be an area of increased
risk, with about half of
the cases resulting in an
unfavourable medico-legal
outcome for physicians.
These were often
associated with delays in
diagnosis that resulted in
permanent injury.
Later that day, the patient visits his family physician
complaining of increasing pain. The physician
prescribes a NSAID and makes an elective referral to
a sport medicine specialist.
After 2 more days pass, the patient presents to
another community hospital ED. The emergency
physician notes marked bilateral weakness of ankle
dorsiflexion and eversion. The patient is discharged
with instructions to attend a hospital with an on-site
orthopaedic service if symptoms persist.
A few days later, the patient presents to a large
university centre where bilateral compartment
syndrome, bilateral foot drop, and rhabdomyolysis
are diagnosed. The condition is considered too
advanced for treatment with fasciotomies.
The CMPA pays a settlement to the patient on behalf
of several member physicians for failing to consider
the diagnosis.
Compartment syndrome explained
Compartment syndrome results from increased
pressure within a limited anatomical compartment,
which can compromise the viability of muscles,
nerves, and other tissues within that space. It most
commonly occurs in the lower leg, however the
forearm, hand, thigh, foot, and buttock are other
possible sites.
When it develops in the lower limb, it is most often
related to tibial fractures and soft tissue injuries.
However, it can also occur in the context of surgical
positioning (“well limb” compartment syndrome).
Compartment syndrome may be characterized
by narcotic-refractory pain out of proportion
to the apparent degree of injury or physical
findings, altered sensation, pain on passive
iStock, Jan-Otto
CASE 2: ANALGESIA MASKING PAIN
An orthopaedic surgeon evaluates a 4-year-old who
is recovering from bilateral tibial osteotomies. She
is receiving epidural anaesthesia. He notes that her
toes are pink and she has no pain on passive motion.
He transfers care to the on-call orthopaedic surgeon
before leaving for the long weekend.
While making rounds later that day, the on-call
orthopaedic surgeon notes that the patient’s right
foot is swollen, but she otherwise appears fine.
A few hours later, a nurse calls him with concerns
about continued swelling and breakthrough pain.
Over the telephone, he gives an order to bivalve the
cast, which is done by the orthopaedic technician
1 hour later. The patient’s epidural is removed, and
intravenous analgesia is increased in an attempt to
alleviate the patient’s pain.
The next day a resident is called about continued
swelling of the patient’s right foot and leg. He notes
that the bivalved cast is taped tightly, but the patient
June 2014
CMPA PERSPECTIVE 15
shows no sign of pain with limited passive motion,
and her toes are pink with good capillary refill.
He re-wraps the bivalved cast loosely and orders
that neurovascular signs be evaluated every hour.
The original orthopaedic surgeon examines the
patient on his return to hospital 3 days postsurgery. He believes she is showing signs of
neuropraxia and orders observation. However,
several weeks post-discharge, it is determined
that the patient had experienced compartment
syndrome, and is left with permanent foot drop.
The CMPA pays a settlement to the patient on
behalf of the physicians for failing to recognize
that the epidural could mask compartment
syndrome pain.
As pain is a cardinal sign of compartment
syndrome, continuous epidural analgesia and
patient-controlled analgesia may be associated
with “pain masking,” making the diagnosis more
difficult. While there is controversy regarding
what types of analgesia are most associated with
pain masking, some hospitals are re-evaluating
regional anaesthesia in patients at risk for
compartment syndrome.
Risk management considerations
The following risk management suggestions are
based on the expert opinions in these cases:
• Consider the risk of compartment syndrome in
patients presenting with extremity injuries or a
history of recent surgical procedures.
• Consider compartment syndrome in the
differential diagnosis of patients with cardinal
symptoms and signs even in the absence of a
fracture or injury.
• If compartment syndrome is a risk of a
proposed surgery, consider including that
possibility in the consent discussion.
16 CMPA PERSPECTIVE
June 2014
• Conduct the appropriate neurovascular
assessments when evaluating a patient at risk
for compartment syndrome.
• Consider if analgesia is masking the pain of the
disorder.
• Consider whether the patient requires
emergent investigation for compartment
syndrome.
• Other healthcare providers should know the
changes in the patient’s condition that would
require immediate attention and notification.
• When discharging a patient at risk for
compartment syndrome, give clear instructions
as to the symptoms and signs that warrant
seeking further medical attention and the
urgency of such evaluation.
• Thoroughly document patient assessments,
including complaints of pain, analgesic
requirements, and the neurovascular
examination. n
ADDITIONAL RESOURCES AT
cmpa-acpm.ca
“Acute compartment syndrome of the lower extremity”
(eLearning activity)
“Well-limb compartment syndrome”
LONG-TERM CARE
Quality decisions
With an aging population and an
increased focus on long-term care, more
physicians will find themselves caring
for patients in long-term care facilities.
Doctors working in this setting bring
a special blend of care, comfort, and
compassion. As physicians may face
unique issues when caring for residents
of long-term care facilities, being aware
of risks will prove beneficial to the
provision of safe care.
Fotolia, Corbis
Communication and collaboration in
long-term care settings
L
ONG-TERM CARE FACILITIES, also
known as residential care homes or nursing
homes, are settings in which communications
with residents, residents’ representatives, and
other health providers are of utmost importance.
Residents may need special consideration when
it comes to communication, most often because
of their age or health status. Doctors will want to
tailor the pace of their conversation according to
the needs of the resident, use easily understood
language and other communication tools, and
check for apparent understanding.
Physicians will likely have to navigate
communications with family members
(sometimes several of them) or substitute
decision-makers. Family members may be easily
available, or in a different geographical location
making communication more challenging. In all
cases, doctors should use plain language, provide
sufficient detail, and encourage questions and
involvement in care planning. Doctors should
also document all patient care discussions in the
patient record.
A review of the CMPA cases involving care
provided in long-term care facilities over a 5-year
period (2008–2012) found that communication
issues between the physician and the resident,
or the resident’s family, was the most common
medico-legal risk. Other risks were related to
deficient evaluations, communication problems
between the physician and other healthcare
professionals, documentation, and resident
monitoring.
Communication and coordination of care between
all providers are critical elements of healthcare
delivery in long-term care settings. Healthcare
professionals, including nurses, provide most of the
care. Physicians need to collaborate, communicate
clearly, and be attentive to information being
provided by all caregivers, whether face-to-face, in
writing, or by telephone. Timely follow-up of test
results and effective patient handovers between
doctors in long-term care settings is also necessary
for safe care.
Results from the
2013 National
Physician Survey
showed nearly
19% of physicians
said they work in a
nursing home, longterm care facility, or
seniors’ residence.1
The CMPA believes clear responsibilities and
accountabilities among professionals in a
collaborative care team are essential to promote
patient safety, reduce risks, and assure the
continuum of care. A well-written medical record
is useful in communicating information among
team members, and documenting residents’ care
and any transfer of care, and serves as a record
for consideration should problems arise in the
future. Team members need to agree on their roles
and responsibilities. Doctors should always be
mindful of the facility’s policies and procedures for
collaborative team functioning.
June 2014
CMPA PERSPECTIVE 17
Long-term care facility regulations
Long-term care facilities are licensed by provincial
and territorial governments, and they must
comply with specific regulations. These regulations
generally outline the responsibilities of healthcare
providers. For example, a physician may act as a
medical officer for the facility, or as an attending
physician for a patient residing in the facility.
While it is the facility’s responsibility to comply
with licensing requirements and other standards,
doctors working in long-term care facilities should
be aware of provincial and territorial standards
designed to protect the rights of residents. Some
provinces and territories have enacted legislation
that establishes, or requires that facilities establish
a bill of rights for residents. The intention is to
make sure long-term care facilities are truly homes
for the people who live in them. Residents’ rights
put residents in charge of their care, and help to
ensure they are treated with respect.
Thinkstock, Fuse
Legislation in most
provinces and
territories provides
a means to obtain
substitute consent
when a resident
is incapable
of giving valid
consent. Substitute
decision-makers
are expected to
act in compliance
with any prior
expressed wishes
of the resident or
in accordance with
the best interests
of the resident if
there were no prior
expressed wishes.
Furthermore, while the obligations and
expectations vary by jurisdiction, physicians
should be aware of their roles and responsibilities
regarding the prevention of abuse of residents in
long-term care homes. For example, the legislation
in some jurisdictions requires physicians and
individuals to report when they have reasonable
grounds to suspect that a resident of a long-term
care home is being, or is likely to be, abused
or neglected. Abuse may be broadly defined to
include suspected misuse or misappropriation of a
resident’s money by the facility operators. In some
cases, the physician may be obliged to take
reasonable steps to protect a patient from
abuse or neglect. Complex issues in long-term care
Physicians working in long-term care contend
with important and complex issues, including
quality of life, medical management (including
often limited mobility), decision-making and
patient autonomy, mental health, artificial
nutrition and hydration, and advance care
planning.2
there is a current and complete medication list
on the resident’s health record. To the extent
possible, doctors should also provide long-term
care residents (or their families) with information
about their medication prescriptions and answer
all relevant questions.
Decision-making and consent
Consent to treatment in long-term care is just as
relevant as in other healthcare settings. With few
exceptions, physicians must obtain valid consent
before treatment is administered or stopped.
Obtaining consent from residents in long-term care
may be challenging due to issues such as cognitive
impairment and dementia. Consent can also be
complicated when family members disagree with
the patient, or with each other.
When discussing care plans or treatments, it is
important to communicate clearly and check for
understanding. Residents and families or substitute
decision-makers need time to ask questions.
Doctors should be careful about accepting waivers
from residents and should seek to engage them in
decisions related to their health and care.
Advance directives
Advance directives are particularly relevant
in long-term care settings. Ideally, residents
have clearly outlined their wishes for care and
treatment, and these are known to all healthcare
providers and family members.
If advance directives are not available, physicians
should attempt to talk to residents about the
medical treatment they desire in the event they
become incapable of making such decisions.
These discussions should be voluntary, and
centred on individuals’ values and beliefs.
Medications
Most long-term care residents take several
medications. This can pose significant risk.
Physicians should be particularly vigilant about
medication prescription and administration,
medication side effects and drug interactions,
and the monitoring and evaluation of residents.
Doctors should complete a resident assessment
before prescribing a new medication, and ensure
18 CMPA PERSPECTIVE
June 2014
Fotolia, Blend Images
Doctors should communicate effectively and
openly with residents, and if appropriate, family
members. Physicians will want to be familiar with
and follow any relevant legislation and regulatory
authority (College) policies regarding end-of-life
care and the withholding of life-saving treatment.
As well, documenting discussions and decisions in
the medical record is important. Physicians may
also consult with colleagues for support regarding
end-of-life care.
• Arrange for on-call coverage when unavailable.
Arrange for timely referrals and transfers.
• Document every resident encounter, especially
when there is a change in the clinical condition
or treatment plan.
Members are encouraged to contact the CMPA
when they need risk management or medico-legal
advice arising from the increasingly complex
issues related to long-term care. n
Risk management considerations
Recognizing the complexity of care required for
many long-term care residents, the following risk
management considerations are offered:
• Actively communicate with residents, and
when appropriate with family members,
regarding the resident’s treatment plan and
medications.
• Return calls from family members.
• Engage with all members of the care team, and
promote the effective exchange of information.
• Participate in care conferences to keep lines
of communication open and to discuss care
options. Care conferences are particularly
important in cases of deteriorating resident
health or disruptive behaviour.
• Ensure ongoing monitoring of medications,
including therapeutic drug levels.
• When there are questions about the treatment
plan or medications, follow up with other
relevant physicians (e.g. previous family
physician) or facilities (e.g. previous acute
care setting).
ADDITIONAL READING AT
cmpa-acpm.ca
“Risk management in elderly patients:
Medication issues”
“The aging patient – Responding to changing
demographics”
“Providing end-of-life care “
1. The College of Family Physicians of Canada, Canadian Medical Association, The
Royal College of Physicians and Surgeons of Canada. 2013 National Physician
Survey. Retrieved on November 1 2013 from http ://nationalphysiciansurvey.ca/
wp-content/uploads/2013/08/2013-National-EN-Q17a.pdf
2. University of Toronto. Curriculum: Ethical issues in geriatrics and long-term care.
Retrieved on October 31 2013 from http ://www.utoronto.ca/pgme/documents/
curricula/geriatric_curriculum.pdf
When discussing care plans or treatments, it is important to communicate clearly
and check for understanding. Residents and families or substitute decision-makers
need time to ask questions. Doctors should be careful about accepting waivers
from residents and should seek to engage them in decisions related to their health
and care.
June 2014
CMPA PERSPECTIVE 19
OTTAWA
CMPA Annual Meeting and
Information Session
1:30 p.m.
ANNUAL MEETING
• President’s report
• Financial reporting for 2013
• Announcement of the 2015 aggregate fee by region
• Election results for CMPA Council
• Q&A for members
2:45 p.m.
Wednesday, August 20, 2014
Ottawa Convention Centre
The impact of
BIG DATA
on medical care
INFORMATION SESSION
• The impact of big data on medical care
Members who wish to initiate a motion for consideration
during the annual meeting in Ottawa should complete and
sign the Notice of Motion form and support for Notice of Motion
form at least 60 days prior to the meeting. Details regarding the
annual meeting and forms are available at cmpa-acpm.ca.
Draft minutes of the 2013 annual meeting are now available
at our website.
For information: 1-800-267-6522 or [email protected]
Contact us for any accessibility requirements.